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Conventionally, this clinical condition is defined by the presence of delayed bone age (at least 2 SD) compared to chronological age associated with short stature, a delay in both pubertal maturation, as well as in the achievement of adult height, compared to peers. The determination of bone age is important to properly assess and guide the evaluation of short or tall stature, impaired or accelerated growth, and delayed or early puberty (10). doi: 10.1136/adc.81.2.172, 94. X-rays should be perpendicular to the rigid plane and usually be performed with a tube of 4560 kVp potential. By evaluating the data obtained from bone age in the clinical setting, it is possible to distinguish three main groups of subjects: patients with delayed bone age, patients with bone age appropriate to chronological age, and patients with advanced bone age (3, 810). Formation of the human skeletal system begins in fetal life with the development of a loosely ordered connective tissue known as mesenchyme. The issue here is the size of the standard deviation (SD) of the difference between bone age and chronological age, which is 15 months or more. (2013) 19:615. There have been two updates since the first publication of the TW method in 1962: the TW2 method in 1975 and the TW3 method in 2001. It is important to highlight that all the available methods might be carefully used in the daily clinical approach in order to avoid unreliable expectation in children and parents. doi: 10.1016/j.forsciint.2011.09.022, 101. /content/kidshealth/misc/medicalcodes/parents/articles/xray-bone-age, diseases that affect the levels of growth hormones, such as growth hormone deficiency, hypothyroidism, precocious puberty, and adrenal gland disorders, orthopedic or orthodontic problems in which the timing and type of treatment (surgery, bracing, etc.) The Nemours Foundation. In: Preedy V, editor. Thiago O, Artiol MA, Alvares VS. 113. doi: 10.1016/S0022-3476(73)80481-0, 19. Karyotyping in girls might also be reasonable because short stature and delayed puberty may be the only symptoms in some girls with Turner syndrome. This means a child tends to be shorter than average and to enter puberty later than average, while growing at a normal rate. (2010) 7:26674. J Pediatr. The Pediatric Endocrine Society website was searched for consensus statements and clinical guidelines. doi: 10.1007/BF02171555, 116. Hum Biol. doi: 10.1520/JFS2005020. Although encouraging results have been shown, this method still requires improvements in terms of reproducibility and elimination of confounding factors (135, 136). As well, hypophyseal alterations secondary to malformation, tumor, or infiltrative pathologies may also be associated with bone age delay consequently to a secondary GH deficiency or hypothyroidism. In the last 20 years, newer methods have also been studied with the principal aim to mainly eliminate the variability related to interpretation according to the different methods. (2009) 12:7026. Tanner-Whitehouse method of assessing skeletal maturity: problems and common errors. This method is valid for children above the age of 4. Thus, the variability in the bone age at onset of puberty was greater than the variability in the chronological age at onset of puberty ( Fig. The bibliographies of review articles and textbook chapters were also reviewed for original research articles. In the United States, the most common technique for estimating a person's bone age is to compare an x-ray of the patient's left hand and wrist to a reference atlas containing x-ray images of the left hands of children considered to be representative of how the skeletal structure of the hand appears for the average person at a given age. doi: 10.1056/NEJMoa064725, 62. 134. It is based on a computerized system obtained from a series of measurements provided by a large reference population. CG has organized the material. J Pediatr. Tanner JM HM, Goldstein H, Cameron N. Assessment of Skeletal Maturity and Prediction of Adult Height (TW3 Method). The bone age (also called the skeletal age) is measured in years. Acharya SV, Gopal RA, Lila A, Menon PS, Bandgar TR, Shah NS. doi: 10.1258/ar.2012.120443, 122. A total 156 samples were selected convenient sampling to make comparison of bone age and chronological age between thalassaemic children (age 9-15years) and age sex matched normal control. In this study of prepubertal children with and without obesity and/or PA, obesity was highly associated with BA advancement. Contemporary Pediatrics Resident Writer Program, Food Insecurity and the Dangers of Infant Formula Dilution, Getting into the Roots of Childhood Atopic Dermatitis, Opt-Out Chlamydia Screening in Adolescent Care, The Role of the Healthcare Provider Community in Increasing Public Awareness of RSV in All Infants, | Obstetrics-Gynecology & Women's Health. By A. F. Roche, W. C. Chumlea, and D. Thissen. doi: 10.3923/pjbs.2009.702.706. The main advantage of this procedure related to the evaluation of each bone segment, thus minimizing the interoperator variability. For this reason, in the TW3 method, skeletal age evaluation ends at 15 years in women and 16.5 years in men (while in the TW2 set, 18 and 19 years, respectively, with a bone maturity anticipation of 2.53 years) (120). (2005) 35:42933. (2006) 91:420514. New technology for bone age determination includes computer-automated readings and assessments obtained from alternative imaging modalities. A score is assigned to each bone based on maturation and sex of the patient. Ossification centers are defective, appearing in an irregular and mottled pattern, with multiple foci that coalesce to give a porous or fragmented appearance. (2015) 51:235. doi: 10.1111/jpc.12837, 61. Henley DV, Lipson N, Korach KS, Bloch CA. Age determination in refugee children: A narrative history tool for use in holistic age assessment. Malina RM, Rogol AD, Cumming SP, Coelho e Silva MJ, Figueiredo AJ. doi: 10.1093/qjmed/hcs230, 66. Child Adolesc Psychiatry Ment Health. Garn SM, Rohmann CG. (2014) 30:40911. When hypothyroidism is acquired during growth, secondary centers of ossification are predominantly affected, with delayed fusion of epiphysis and with an irregular and heterogeneous ossification. (2010) 126:93844. Bone age (BA) is a measure of the development of the skeleton incorporating the size, shape and degree of mineralization of the epiphyses and physeal plates of a bone to define their proximity to full maturity [1].BA differs from chronological age (CA), which is calculated from the date of birth and does not necessarily reflect an individual's stage of puberty. Eur J Pediatr. Horm Res. (1994) 7:1415. So the confidence interval around the chronological age estimated from bone age is 30 months (i.e. [16], The bones considered in the TW3 method include the distal radius and ulna, the metacarpals and phalanges of the 1st, 3rd, and 5th fingers, and all of the carpal bones except the pisiform. During this stage of development, the ossification centers for the epiphyses increase in width and thickness, becoming as wide as the metaphyses. (2010) 60:5525. Forensic Sci Int. William Walter Greulich and Sarah Idell Pyle published the first edition of their standard reference atlas of x-ray images of the left hands and wrists of boys and girls in 1950. Although most children with short or tall stature have variants of normal growth, children who are more than three standard deviations from the mean for age are more likely to have underlying pathology. Of these, 5477 participants (2975 female [54.3%]) had bone measurements from at least 1 age after peak height velocity . N Engl J Med. doi: 10.1002/mpo.2950210104, 40. . It is also possible to evaluate a physiological variant of familial early puberty (14), especially in some ethnic groups (15, 16). Bone age is measured in years and assigned by a trained radiologist or endocrinologist by comparing the child's measurements with existing standards. Ostojic SM. The bones on the X-ray image are compared with X-ray images in a standard atlas of bone development. Briers PJ, Hoorweg J, Stanfield JP. See permissionsforcopyrightquestions and/or permission requests. However, data obtained from the assessment of bone age can be widely used both in medical or nonmedical settings. Available online at: https://treaties.un.org/Pages/ViewDetails.aspx?src=IND&mtdsg_no=IV-1&chapter=4&clang=_en. Although most children with short or tall stature do not have a pathologic condition, extremes of height, especially beyond three standard deviations, require further workup. | Food Insecurity and the Dangers of Infant Formula Dilution, | Getting into the Roots of Childhood Atopic Dermatitis, | Opt-Out Chlamydia Screening in Adolescent Care, | The Role of the Healthcare Provider Community in Increasing Public Awareness of RSV in All Infants, | Update in Pediatric COVID-19 Vaccines, https://kidshealth.org/en/parents/xray-bone-age.html. Constitutional delay of growth and pubertal development. Is the assessment of bone age by the Greulich-Pyle method reliable at forensic age estimation for Turkish children? Int J Legal Med. J Obstet Gynaecol Res. In Italy, a multidisciplinary approach is suggested to evaluate bone age using the GreulichPyle TW3 methods for a complete characterization of chronological age of the refugee. This information, associated to the characterization of the shape and changes of bone components configuration, represent an important factor of the biological maturation process of a subject. The choice of the left hand depends on the fact that, at the time of sampling, the left hand was the less frequently impaired (at that time, many boys used to work in factories, and they could have suffered accidents at work). doi: 10.1080/03014468700009141, 118. In addition, subjects with long-lasting and untreated growth hormone (GH) deficiency have a delay in bone maturation. Among these, three methods were the most representative and used worldwide: The GreulichPyle method, the TannerWhitehouse, and the Fels method. Loder RT, Estle DT, Morrison K, Eggleston D, Fish DN, Greenfield ML, et al. The mean growth velocity ranges from 8 to 10 cm/year, roughly +2 to +4 SD for chronological age, and results in increased heights, between +1.5 and +2.5 SD for age on average. Most children with short stature have normal variants such as familial short stature, constitutional delay of growth and puberty, or idiopathic short stature. 2nd ed. Cox LA. 1, Fig. In particular, these prediction tables are developed from the GreulichPyle standards for hands, thus with the expectation that they will be used in conjunction with these standards (137, 138). 42. There are extremes to be mindful of, Kutney added. Computer-assisted phalangeal analysis in skeletal age assessment. As well, height prediction methods might be affected by ethnicity-related differences, thus either underestimating or overestimating adult height, with wide variations in accuracy. Other causes include renal, hepatic, and gastrointestinal diseases, and other genetic syndromes.1015, The initial evaluation of short stature (Figure 1) should include a history and physical examination, accurate growth assessment, calculation of the growth velocity and midparental height, and radiography to evaluate bone age.16 Drugs known to cause short stature include steroids (chronic use), attention-deficit/hyperactivity disorder medications, and anticonvulsants. J Pediatr Endocrinol. Table 1. defects in bone mineralization process (commonly found in osteochondrodysplasia). [11], A drawback associated with the Greulich and Pyle method of assessing bone age is that it relies on x-ray imaging and therefore requires exposing the patient to ionizing radiation. Br J Sports Med. The long bones of the leg comprise nearly half of adult height. A longitudinal study. After puberty, all carpals, metacarpals, and phalanges are completely developed, their physes are closed, and the assessment of skeletal maturity is based on the degree of epiphyseal fusion of the ulna and radius (8082). (2008) 28:1016. For a correct interpretation of data, it is important to follow a correct procedure: the hand (conventionally the left hand) is positioned with the palm side resting on a rigid plane with fingers spread out to obtain an antero-posterior radiograph. Giovanni XXIII Children's Hospital, Italy, University of Modena and Reggio Emilia, Italy, Children's Hospital at Montefiore, United States. Because children grow in spurts, two measurements at least three to six months apart, and preferably six to 12 months apart, are needed to accurately determine growth velocity.4. AJR Am J Roentgenol. Bone age assessments can provide pediatricians with a rough estimate of when a child will enter puberty, Kutney stated. This information, associated with the characterization of the shape and changes of bones, represents an important factor of the biological maturation process. It uses feature extraction techniques and calculates bone age by analyzing the left-hand radiograph based on. Med Pediatr Oncol. Bone age in children of diverse ethnicity. 6. Tanner JM WR, Cameron N, Marshall WA, Healy MJR, Goldstein H. Assessment of Skeletal Maturity and Prediction of Adult Height (TW2 Method). Forensic Sci Int. A delayed bone age is common in malnourished conditions associated with chronic diseases such as intestinal inflammatory chronic diseases, celiac disease, and cystic fibrosis (2629). Cox LA. It is a safe and painless procedure that uses a small amount of radiation. These different methods are characterized by a significant and variable intraindividual variability with values ranging from 0.96 to 0.74 years, which seems to be strongly affected by several factors including ethnicity, gender, and pubertal age (93105). The most common measurement standards used for bone age are the Greulich and Pyle Atlas 2 and the Tanner-Whitehouse 3 assessments. 9:580314. doi: 10.3389/fped.2021.580314. Chronological age and bone age were 8.7 4.0 and 8.8 4.3 years, respectively, for the entire population. Automatic determination of Greulich and Pyle bone age in healthy Dutch children. 5. Bass S, Pearce G, Bradney M, Hendrich E, Delmas PD, Harding A, et al. Typically, children with this condition have a delayed bone age with a preserved or increased weight for age. Bone age may be significantly advanced in genetic overgrowth syndromes, such as Sotos syndrome, Beckwith-Wiedemann syndrome and Marshall-Smith syndrome. Results: At the time of diagnosis, the chronological age was 9.90.6 years, the bone age was 11.61.0 years, and the bone age/chronological age ratio was 1.200.1. Peak height velocity (PHV) occurs at the average age of 11 years for girls and at the average age of 13 years for boys. 93. Comparison of dental maturity in children of different ethnic origins: international maturity curves for clinicians. doi: 10.1111/jpc.13114, 75. Among these, three methods are the most representative: GreulichPyle method, TannerWhitehouse method, and Fels method. It is also common in chronic inflammatory states or infectious diseases, such as juvenile idiopathic arthritis and states of immunodeficiency (3037). This content is owned by the AAFP. J Pediatr. Khan KM, Miller BS, Hoggard E, Somani A, Sarafoglou K. Application of ultrasound for bone age estimation in clinical practice. Spec Care Dentist. (2014) 12:2005. Soudack M, Ben-Shlush A, Jacobson J, Raviv-Zilka L, Eshed I, Hamiel O. Recent studies show that organs like the liver can also be used to estimate age and sex, because of the unique feature of liver. Jung H. The radiation risks from x-ray studies for age assessment in criminal proceedings. Data Sources: We searched PubMed, Agency for Healthcare Research and Quality, Cochrane Database of Systematic Reviews, and National Guidelines Clearinghouse. 2019;29(6):2910-2923. doi:10.1007/s00330-018-5792-5. Br J Radiol. The effects of long-term medication on growth in children and adolescents with ADHD: an observational study of a large cohort of real-life patients. In patients with pituitary gigantism, octreotide (Sandostatin) and pegvisomant (Somavert) have been used to suppress the growth hormone.19. (1992) doi: 10.1017/CBO9780511661655, 127. 47. Pathologic causes of short stature include chronic diseases; growth hormone deficiency; and genetic disorders, such as Turner syndrome. Introduction. Congenital hypothyroidism leads to growth arrest, delayed bone age, and short stature at birth. Between six and 18 months of age, children exhibit catch-up or catch-down growth until they reach their genetically determined growth curve based on midparental height. doi: 10.1111/j.1754-4505.2008.00020.x. Wong SC, Smyth A, McNeill E, Galloway PJ, Hassan K, McGrogan P, et al. Angle Orthod. The bone ages of hand and elbow were different at puberty, and the elbow was a more reliable location for bone-age assessment at puberty. Short stature is defined as a height more than two standard deviations below the mean for age (less than the 3rd percentile). Finally, the bone age (BA) is an assessment of the degree of skeletal maturation. Apart from the ability to assess the chronological age of a person, the evaluation of growth remaining in a person can be extremely beneficial to a clinician in different circumstances, as previously discussed. doi: 10.1159/000184848, Keywords: skeletal development, height, X ray, children, bone age, Citation: Cavallo F, Mohn A, Chiarelli F and Giannini C (2021) Evaluation of Bone Age in Children: A Mini-Review. Ann Hum Biol. 69. (1998) 75:4929. Tanner J, Oshman D, Bahhage F, Healy M. Tanner-Whitehouse bone age reference values for North American children. Olesen T, Egeblad M, Dige-Petersen H, Ahlgren P, Nielsen AM, Vesterdal J. Somatic manifestations in children suspected of having been maltreated. Buken B, Safak AA, Yazici B, Buken E, Mayda AS. doi: 10.1210/er.2015-1106, 20. doi: 10.1007/s00247-004-1385-3, 136. Most children will achieve a final height within 4 inches of the mid-parental height estimate, she said. Herman TE, Crawford JD, Cleveland RH, Kushner DC. We present three pre-pubertal female children with a diagnosis of NC-CAH treated with anastrozole monotherapy after presenting with advanced bone age, early adrenarche, no signs of genital virilization, and normal peak cortisol in response to ACTH stimulation. The bone age study can help evaluate how fast or slowly a child's skeleton is maturing, which can help doctors diagnose conditions that slow down or speed up physical growth and development. In several conditions involving atypical growth, bone age height predictions are less accurate. doi: 10.1136/adc.65.10.1109, 14. Because of this, those who are short with an advanced bone age, need medical attention before their bones fully fuse. A small amount of spinal growth concludes an adolescent's growth. It is defined by the age expressed in years that corresponds to the level of maturation of bones. Sopher AB, Jean AM, Zwany SK, Winston DM, Pomeranz CB, Bell JJ, et al. Over the years, many standardized methods have been developed to evaluate a skeletal maturity score for hand and wrist X-rays. Bayley N, Pinneau S. Tables for predicting adult height from skeletal age. Available online at: https://www.rch.org.au/immigranthealth/clinical/Birth_date_issues/. Philadelphia, PA: Mosby (2008). Dense body parts, such as bones, block the passage of the X-ray beam through the body. Forensic Sci Int. (2008) 18:21723. (2014) 20:627. doi: 10.1016/j.forsciint.2012.08.030, 105. During growth, biological maturity is defined by several parameters, including the characterization of skeletal maturity, sexual maturity, dental elements eruption, menarche, spermarche, deepening of the voice, growth spurt, and the achievement of 95% of the adult height (13). 91. A newborn's size and growth are a result of the intrauterine environment, and growth hormone does not play a major role. (2015) 173:63342. Van Rijn RR, Thodberg HH. In addition, studies have shown that, in some bones, ossification typically begins at birth, while in others, it typically begins between 14 and 17 years of life. Puberty timing plays a big role in growth, too. doi: 10.1016/j.jflm.2013.11.011, 98. If bone age reading is performed with the TannerWhitehouse method, there are some equations proposed by Tanner to calculate growth prognosis (10, 122, 123). doi: 10.1007/s00247-011-2302-1. doi: 10.1259/0007-1285-67-801-848, 95. However, the GP method requires a continuous and long experience in order to optimize bone age determination. p. 70932. Introduction: Bone age (BA) is a quantitative determination of skeletal maturation. An X-ray of the left hand and wrist will measure your child's bone age. Automatic bone age measurement using computerized image analysis. In fact, the bone maturation process lasts longer in male than in female individuals (8385), and the moment of closure of the epiphyseal region occurs is roughly 2 years earlier in girls than in boys. doi: 10.1136/bcr-2015-212216, 58. doi: 10.1210/jc.2006-1645, 13. Children with normal variants of height tend to have a normal growth velocity (5 cm [2 in] per year for children between five years of age and puberty) after catch-up or catch-down growth. The height age (HA) refers to the CA at which a child's height would be at the 50th percentile for age and sex. Projected height can be estimated by projecting the current growth curve to adulthood in children with normal bone age, or by using a bone age atlas in those with delayed bone age.. The following are generally documented (84, 97105): a delay in bone age in Middle-Eastern men and Iranian men and in Southeast Asian children (Indonesian and Indian men and women) and Asian-American men; an advanced age in Afro-American children (more in female than in male) and in Middle Eastern female children (Iranian girls); no variation is documented for Italian, Korean, and Scottish children and in Pakistani girls. Children with cardiac diseases, or those with chronic kidney or liver disease, may experience a delay in skeletal maturation (3842). GreulichPyle distinguished two standard templates: 31 and 27 radiographic images, in male and female individuals, respectively, which illustrate different phases of bone maturation between 0 and 18 or 19 years, respectively. Genetic potential is determined by mid-parental height, which is calculated by averaging sex-adjusted parental heights.Kutney shared the following examples. Albanese A, Stanhope R. Predictive factors in the determination of final height in boys with constitutional delay of growth and puberty. Copyright 2023 American Academy of Family Physicians. Evaluation may also be needed in a child who has a normal height, but a projected height more than two standard deviations from the midparental height. Nemours Children's Health and KidsHealth are registered trademarks of The Nemours Foundation. A fuller description of the use of bone age films from the University of Utrecht. doi: 10.1109/42.108597, 128. Statistics have been compiled to indicate the percentage of height growth remaining at a given bone age. This method has the advantage of eliminating the need for additional radiographic exposure in cases where the vertebrae have already been recorded on a lateral cephalometric radiographic. Handbook of Growth and Growth Monitoring in Health and Disease. The CDC and WHO growth charts are available at http://www.cdc.gov/growthcharts/ and http://www.who.int/childgrowth/standards/en/. However, this system has some limits that must be considered, in particular, the absence of carpal bones evaluation, the opposition of local administrations to install the software, and the higher cost compared to available methods (GP and TW) (134).